Gipps Street Permit

Date of Request *

Requested by *

Company *

Contact Number *

Contact Email *

Please sign below to confirm that you have read the Gipps Street Site Specific WHS Summary document and/or the Long Term Environment Management Plan as part of submitting this permit.

Signature *

Description of works *

Reason for Permit Request *

Subsurface works within 1 m of a building

Hot works in or within 1m of a building

Penetration of building concrete slabs

Confined Space Works

Any works that involve ground penetration or excavation that will reach within 200mm of the bottom of the original capping layer

Ground penetration or excavation that will reach within 200mm of the bottom of an asbestos management area

Location of works *

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Job Specific Safe Work Method Statement (required for all permit requests) *

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Fill and spoil management plan

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Underground Service Check Details

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Details of proposed landfill gas and asbestos monitoring to comply with LTEMP requirements

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Details licensed asbestos removal contractor (see note below)

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Details licensed asbestos assessor contractor (see note below)

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Hot Works Permit *

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Confined Space Permit *

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Please refer to the Gipps Street Work Permit Information sheet and the Gipps Street Reserve - Environmental and Safety Requirements Document for more information.

Gipps Street Work Permit Information Sheet

Gipps Street Reserve - Environmental and Safety Requirements

Last Name